Visa Constraints and Career Choices for Oncologists
Authors: Farah Mazahreh, Ahmad A. Al-Hader, Samer Al Hadidi
Journal: Journal of the National Comprehensive Cancer Network (2023)

T he number of international medical graduates (IMGs) applying for residency in the United States is increasing, as is the number of IMGs applying for fellowship training, particularly in hematology and medical oncology.From 2020 to 2021, the number of applicants for hematology and medical oncology fellowships increased from 909 applicants to 1,010 applicants.In 2021, internal medicine had the highest match rates for both IMGs who were US citizens and IMGs who were not US citizens; this accounted for 40% of all filled positions. 1According to the 2021 match results for medical specialties, approximately 1 in every 3 fellows who matched in hematology and medical oncology required visa sponsorship.A shortage of physicians in medical subspecialities (anywhere between 3,800 and 13,400 physicians), including medical oncology, is expected by 2034. 2 Thus, the IMG workforce will be needed to help reduce the severity of the physician shortage in subspecialities.IMGs who are not US citizens require visa sponsorship to complete residency and fellowship training in the United States.The most common visa used by IMGs without US citizenship is the J-1 visa, also known as the exchange visitor visa.Few residency and fellowship programs allow for H-1B visa sponsorship.Once a trainee starts their J-1 visa sponsorship, they cannot switch to an H-1B visa without completing a waiver process or the 2-year home country physical presence requirement (ie, leaving the United States for at least 2 years to work in their home country).The waiver process is variable, state-dependent, and governed by deadlines, availability, and specific rules for application (Figure 1).Overall, primary care physicians are more likely than specialists to be provided with a J-1 visa waiver.ASCO released its Workforce Information Systems (WIS) report in which they annotated the available annual data on the supply of oncologists and the incidence and prevalence of cancer.ASCO reported that IMGs were more prevalent in training programs than in current practice; this may be due, at least in part, to the regulations that limit the choices that IMGs can make when joining the current oncology workforce after completing medical training. 3areer choices are affected by visa status; in a survey of 220 physicians, 97 of which were IMGs, 74% of physicians reported that visa status affected career choices, and 63% of graduates were unaware of resources to help navigate visa status and its implications. 4A different survey reported that 40% of fellows who trained at academic centers (ie, NCI-designated Cancer Centers or NCCN Member Institutions) chose nonacademic careers; however, visa status was not assessed in this survey. 5MGs holding a J-1 visa who desire to practice medicine in the United States after finishing training are required to secure a J-1 waiver job (a 3-year contract) through a long, costly process that is governed by uncertainty.The Conrad 30 waiver program is the most common program; it allows an IMG with a J-1 waiver to bypass the 2-year foreign residence requirement upon completion of the J-1 exchange visitor program.The program addresses the shortage of qualified doctors in medically underserved areas and is particularly focused on addressing the shortage of primary care physicians.Although J-1 waiver jobs were primarily implemented to address the shortage of physicians in medically underserved areas within the United States, this might prevent IMGs from pursuing their top career choices.This may be particularly relevant to IMGs who hope to pursue an academic career, as few academic programs offer waiver jobs.